A 26-year-old man is brought to the emergency department after a severe motor vehicle collision. Primary survey reveals an unstable pelvic fracture. Genitourinary examination shows blood at the urethral meatus, a scrotal hematoma, and a high-riding prostate on digital rectal examination. A transurethral Foley catheter has not been placed. Arrange the following steps in the most appropriate sequential order for the diagnosis and definitive management of this patient's urologic injury.
- 1Perform a retrograde urethrogram (RUG)
- 2Place a suprapubic cystostomy tube
- 3Allow time for pelvic hematoma and acute inflammation to resolve
- 4Perform definitive delayed formal urethroplasty
Answer
The correct sequence is to first perform a retrograde urethrogram, followed by placing a suprapubic cystostomy tube, then allowing time for the pelvic hematoma to resolve, and finally performing a delayed formal urethroplasty.
The correct sequence strictly follows the standard of care for posterior urethral injury. First, a retrograde urethrogram (RUG) is mandatory to definitively diagnose a urethral tear, as transurethral catheterization is strictly contraindicated. Second, once the RUG demonstrates extravasation indicative of a disruption, the bladder must be drained using a suprapubic cystostomy tube. Third, the patient is discharged with the suprapubic tube in place to allow the massive pelvic hematoma to resorb and the acute inflammation to subside, which typically takes 3 to 6 months. Finally, once the tissues are stable and healed, a definitive delayed formal urethroplasty is performed.
Step-by-Step Solution
Key Concept
In patients with pelvic fractures and signs of urethral injury (blood at the meatus, high-riding prostate), a retrograde urethrogram must be performed before any catheterization. Complete posterior urethral injuries are managed initially with suprapubic cystostomy, followed by delayed urethroplasty.